Healthcare Provider Details

I. General information

NPI: 1457996365
Provider Name (Legal Business Name): DENTISTRY FOR CHILDREN OF IOWA 2, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1738 LININGER LN
NORTH LIBERTY IA
52317-2316
US

IV. Provider business mailing address

1350 SPRING ST NW STE 600
ATLANTA GA
30309-2870
US

V. Phone/Fax

Practice location:
  • Phone: 319-665-2573
  • Fax:
Mailing address:
  • Phone: 770-692-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMONIA LEONARD
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 678-244-4844